Company:



Company: | | |

| |(Name and address of License Holder = Contractual Partner of TRLP) |

| | |

|Address: | |

To

TÜV Rheinland LGA Products GmbH

D-90431 Nürnberg

GERMANY

Declaration

We acknowledge the products marked with the following brand

(trade mark or name signature) as our products:

|Sketch of original trade mark or name signature: |

|(Here goes a copy of the rating plate = rating label which is intended to be placed on the product. It should at least contain the product type|

|designation and name of the manufacturer or his trade name or his registered company logo. If the space is not sufficient, please use extra |

|page(s). |

|Please observe: |

|All type designations and/or trade names not explicitely listed on valid certificates are considered not to be covered under the certificate.) |

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